Download Anesthesia for Organ Transplantation

Anesthesia for Organ
Transplantation
By Anselmo Serna
Greg McMichael
All vital organs: Heart, Lung, Liver and
Kidney, can be supported by
technology or replaced by
transplantation.
Except the brain, it is the only organ that cannot be functionally
supported or replaced.
Transplantation
Expertise in the anesthetic management of the
organ recipient as well as the organ donor has a
major impact on the quality of the graft organ,
the viability of the transplanted graft, and as a
result the long term survival of the transplant
recipient.
 Training in organ transplantation anesthesia will
result in better initial management of these
patients, innovative therapeutic interventions in
the future, and improved outcome among
transplanted patients.
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How much does an organ
transplant cost?
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Bone Marrow - $250,000
Heart - $300,000
Heart/Lung - $300,000 to $350,000
Isolated Small Bowel Transplant - $350,000
Kidney - $75,000 to $100,000
Kidney/Pancreas - $150,000
Liver - $250,000
Lung - $200,000 to $250,000
Pancreas - $100,000
Most Transplant Patients...
Are in surgery approximately 3-7 hours
 Spend 1 day on the ventilator
 Spend 1-2 days in the intensive care unit
 Are discharged 7-12 days after their
surgery
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Reasons not to transplant
Advanced heart, kidney or liver disease
HIV infection
 Cancer
 Hepatitis B
 Hepatits C with proven cirrhosis by liver biopsy
 Current substance abuse: tobacco, alcohol and illicit
drugs
 Body weight less than 80% or greater than 120% of
predicted
 Inability to carry out the responsibilities necessary to
maintain a healthy lifestyle and remain compliant with all
medications
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Candidacy for Transplantation
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The evaluation consists of:
Bloodwork
Urine tests
Radiologic tests
Heart and Lung tests
Tests for osteoporosis
Dental consult
Interview with a social worker
Gastrointestinal consult for patients with scleroderma or
a history of reflux
Females: pap smear and mammogram
Transplantation
Transplantation is a multidisciplinary field that
encompasses a wide range of basic and clinical
medical and biological sciences.
 The science of transplantation constitutes a
biochemical, pathophysiologic, and clinical
continuum from organ donor to organ recipient.
 A better understanding of the biochemical,
pathophysiologic and clinical problems
encountered in the management of the organ
transplant recipient and organ donor can be
achieved through a broad based multidisciplinary
approach.
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Liver Transplants
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Liver transplants are performed in many centers across
the country. The healthy liver is obtained from a donor
who has recently died but has not suffered liver injury.
The healthy liver is transported in a cooled saline
solution that preserves the organ for up to 8 hours, thus
permitting the necessary analysis to determine blood
and tissue donor-recipient matching. The diseased liver
is removed through an incision made in the upper
abdomen. The new liver is put in place and attached to
the patient's blood vessels and bile ducts. The operation
can take up to 12 hours to complete and requires large
volumes of blood transfusions.
Anesthesia Techniques
There is no particular “liver anesthetic.” It is,
however, recommended that a uniform
approach be used initially. For induction and
intubation, fentanyl, sodium
pentothal/etomidate, low dose non-depolarizing
muscle relaxant, and succinylcholine will be
used. Anesthesia will be maintained with
fentanyl, benzodiazepines, non-depolarizing
muscle relaxant, and isoflurane in air/oxygen. 5
cm PEEP will be used to reduce the risk of air
emboli and to prevent atelectasis.
 Use caution in administering N2O as its use may
lead to bowel distention and can compromise
surgical exposure.
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Preparation
Monitors: central line for fluid
replacement; CVP for monitoring fluid
status; a-line for beat-to-beat monitoring
of heart rate/pressure and multiple blood
draws; foley catheter for urine output
 2 large-bore peripheral IVs (16g or
greater) for blood replacement
 Rapid transfusers
 Fluid and body warmers
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Blood and Blood Products
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Typical transfusion requirements consists
of:
– 15-30 units of PRBCs
– 15-25 units of platelets
– 15-30 units of FFP
– 10-20 units of cryoprecipitate
– Cell saver also helpful in reducing reliance on
donor RBC transfusions
Intraoperatively
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Procedure lasts 4-18 hours and is divided
into three phases:
– Dissection
– Anhepatic
– Revascularization
Dissection
Through a wide subcostal incision the liver
is dissected so that it remains attached
only by the inferior venacava, portal vein,
hepatic artery and common bile duct.
 Previous abdominal procedures greatly
prolong the duration of this phase
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Anhepatic
Once the liver is freed the inferior
venacava is clamped above and below the
liver as well as the hepatic artery and
portal vein
 Liver is then completely excised and
venovenous bypass may be employed at
this time
 Donor liver is then anastomosed to
recipient patient
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Venovenous Bypass
When inferior venacava and portal vein
are clamped marked decreases in cardiac
output and hypotension are typically
encountered. For patients identified at
increased risk for venacava clamping,
venovenous bypass is used.
 Venovenous bypass can help minimize
severe hypotension, intestinal ischemia,
build up of acid metabolites and
postoperative renal dysfunction
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Revascularization
Following completion of venous
anastemosis the venous clamps are
removed and the circulation to the new
liver is completed
 Lastly the common bile duct of the donor
is then connected to the recipient
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Management of liver
reperfusion
Take steps to bring potassium to appropriate level (< 4.0)
Discuss at least 4 ways to reduce potassium
Replace calcium to ensure normal (> 5.0)
Correct lactic acidosis (pH normal)
Appropriate volume infusion to maintain euvolemia
Hemoglobin appropriate (9 – 10 for most patients)
Calcium 100mg/cc attached to iv ready for administration.
Epinephrine 10 mcg/cc attached to iv ready for administration
Epinephrine 20 mcg/cc on baxter pump ready for infusion
Communication with surgeon – OK for reperfusion
Heart Transplant
Indications for Transplant
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Idiopathic or ischemic cardiomyopathy
Viral cardiomyopathy
Inoperable coronary artery disease with congestive
heart failure
LV ejection fraction less than 20%
Amyloidosis
Severe congenital heart disease without other
surgical options
Life-threatening abnormal heart rhythms that do not
respond to other therapy
Inoperable heart valve disease with congestive heart
failure
Most Common Causes of End Stage
Cardiac Failure
Coronary artery disease
 Cardiomyopathy
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– 90 percent of heart transplants
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Congenital and valvular heart disease
– A small percentage of end stage heart failure
Pathophysiology
 End
stage Cardiomyopathy: both systolic
and diastolic dysfunction
 Decreased SV
 Decreased CO
 Decreased O2 transport and exercise
capacity
 Multiple comorbitities usually including
DM, HTN, PVD, renal dysfunction
Compensatory Mechanisms
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Renal retention of NA and H2O
 Increased preload
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SNS stimulation
 Increased HR and contractility
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Increased endogenous catecholamines
 Increased contractility
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Decreased venous capitance
 Increased preload
Failed Compensatory Mechanisms
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Increased Preload
 Dilated LV, Mitral Regurg, pulmonary edema
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Increased afterload
 Hypertrophy
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Increased contractility from increased endogenous
catecholamines
 Leading to a decrease in the sensitivity of the heart and the
vasculature to these agents via a decrease in receptors (downregulation)
 Decrease in the myocardial norepinephrine stores
 Increased afterload
 Decreased CO
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Renal retention of Na and H2O
 pulmonary vascular congestion and edema, ascites
Treatment
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Diuretics
 May result in hypokalemia and hypomagnesemia and hypovolemia
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Slow incremental B-Blockade (metoprolol)
 Can improve hemodynamics and improve exercise tolerance in pts awaiting transplant
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Inotropes (amiodarone, milrinone, enoximone)
 Toxic side effects and increased mortality
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Anticoagulants
 Prevent pulmonary and systemic embolization
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Digitalis
 Weak inotrope with toxic side effects
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Vasodilators (nitrates, hydralazine, ACE inhibitors)
 Decrease the impedance to LV emptying
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Intraaortic balloon counterpulsation
VADs
 Vascular complications and immobilizes pts
 Improves myocyte contractile properties and increases B-adrenergic responsiveness
Donor Caveats
 Donors
can exhibit major hemodynamic
and metabolic changes and thus should
be constantly monitored with inotropic
and vasopressor support
 Hypovolemia
 Myocardial injury
 Catecholamine storm
 Inadequate sympathetic tone due to brainstem
infarct
Donor Cardiectomy
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Median sternotomy and heparinization
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Cannulation of the ascending aorta for cold
hyperkalemic cardioplegia
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SVC ligated, IVC transected to decompress the
heart
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Topically cooled with iced saline
Donor Cardiectomy (cont’d)
After arrest, pulmonary veins are severed
 SVC transected
 Ascending aorta divided just proximal to
the innominate artery
 PA transected at its bifurcation
 Heart is then transported via ice chest
 Upper time limit for ex vivo storage of
human hearts is approximately 6 hours
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Transplantation: Preop
Rapid H&P of recipient due to time constraints
 Equipment and drugs similar to those usually used for
routine cases requiring CPB should be prepared
 Placement of invasive monitoring
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 PA catheter, arterial line, TEE
 CO, PVR, CVP
Aspiration Precautions
 Blood products: CMV negative
 Aseptic technique with broad spectrum antibiotic
prophylaxis
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Transplantation: Intraop
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Induction of Anesthesia balances risk of aspiration of gastric contents with
hemodynamic changes
– High dose narcotic with muscle relaxant and benzodiazepines
– RSI: etomidate, succinylcholine, moderate dose fentanyl
 Most patients called in for transplantation have not fasted and should be considered to
have a full stomach
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Induction should be preformed in the presence of the surgeon, scrub nurse
and perfusionist in anticipation for cardiovascular collapse
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Anticipate altered drug responses due to low CO and slow circulation time
as well as decreased volume of distribution
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Preinduction administration of inotropic agents or pressors optimizes
circulation and minimizes transit time of subsequently administered
anesthetics
Transplantation: Intraop (cont’d)
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Maintenance of Anesthesia
– High dose narcotic, benzodiazepines, muscle
relaxant, O2, low dose volatile agent
 High dose narcotic can cause ventricular
arrhythmias
 Volatile agents can cause pre-CPB hypotension
– OG and foley placed
– The PA should be withdrawn from the right
heart prior to completion of bicaval
cannulation
Cardiopulmonary Bypass
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Hypothermia 28-30* C
Furosemide to promote UO
Hemoconcentration for expanded blood volume
Anastamosis: LA, RA, PA, aorta
Glucocorticoid (methylprednisone 500 mg) is administered as the last anastamosis is
being completed prior to the release of the aortic cross clamp to attenuate any
hyperacute immune reaction.
TEE used to monitor whether the cardiac chambers are adequately de-aired and can
diagnose atrial torsion, RV outflow obstruction, and decreased R or L ventricular
systolic function
Longer rewarming period
During reperfusion, an infusion of an inotrope is begun for both inotropy and
chronotropy
Donor heart should be paced if bradycardic despite inotrope infusion also the
possibility of IABP, ECMO, or LVAD
RV dysfunction from elevated PVR is the most common cause of perioperative heart
failure, use of pulmonary vasodilators: milrinone, nitric oxide, sodium nitroprusside
Arrhythmias: slow junctional or AV nodal, V fib
Transplantation: Postop
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Low CO after transplant may be due to: hypovolemia, inadequate
adrenergic stimulation, myocardial injury during harvesting, acute rejection,
tamponade, sepsis.
Systemic hypertension may be due to pain, adequate analgesia is provided
before vasodilators
Atrial and ventricular tachyarrythmias are common in the immediate postop
period, once rejection has been ruled out, antiarrythmics are used for
conversion (except those with indirect acting mechanisms or negative
inotropes)
Many patients require pacing in the immediate postop period and 10-25%
require permanent pacing
Renal function often improves following transplantation, but
immunosuppressants may again impair renal function
Bacterial pneumonia is very common in the early postop period and
opportunistic viral and fungal infections after the first several weeks
Pharmacological Agents After
Transplant
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The transplanted heart has no autonomic
innervation
Agents that act indirectly via the sympathetic or
parasympathetic system (atropine, ephedrine)
will be ineffective.
Drugs with a direct/indirect effect will only have
their direct effect seen.
Drugs of choice are direct effect – isoproterenol,
epinephrine, etc.
May require pacing
Cardioactive Drug Responses in the
Denervated Heart
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Adenosine
Atropine
Digoxin
Edrophonium
Ephedrine
Norepinephrine
Pancuronium
Phenylephrine
Nifedipine
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Supersensitivity
No vagolytic effect
No vagotonic effect
No vagotonic effect
Less cardiostimulation
Unmasked beta effects
No vagolytic effect
Diminished sensitivity
Nodal conduction not
depressed
Anesthesia for Patients With
Previous Transplant
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Transplanted patients require anesthetic for surgical procedures that may or may not
be cardiac related
Preoperative evaluation includes extensive reevaluation of cardiac function
Systolic function is usually normal but a significant number of patients develop
diastolic dysfunction, manifested as exercise intolerance
Abnormalities in isovolumic relaxation time correspond with varying degrees of
rejection
Increased peak inflow velocity and mitral deceleration are indicators of restrictive
filling
Rejection causes inflammatory infiltrate that causes edema
The presence of rejection increases perioperative morbidity and the incidence of
asymptomatic arrhythmias
Complication related to immunosuppression should be considered, including
opportunistic infections
Immunosuppressants side effects include nephrotoxity as well as neurotoxicity and
cyclosporin is associated with cholelithiasis, increasing the incidence of
cholecystectomy in these patients
Repeated biopsies for routine transplant management may cause injury to the
tricuspid valve with severe tricuspid regurg
 Often requires tricuspid valve replacement
Anesthesia for Patients With
Previous Transplant
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Choice of anesthetic depends on the type of surgery and condition of the patient
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Regional anesthesia can be used cautiously, with the knowledge that these patients
cannot mount the usual response to vasodilation and hypotension
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Cardiovascular monitoring is dependent on the nature of the planned surgery.
Invasive monitoring is not necessary for minor procedures. Intraoperative
echocardiography is important in managing volume status.
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The ECG may have a double P wave, reflecting atrial activity in the native atrial cuff
and the transplanted atrium
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Cardiac output of the transplanted heart is preload dependent and rely on changes in
stroke volume. Ephedrine or isoproterenol should be readily available to treat
bradycardia as atropine will not have an effect.
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Patients with prior heart transplantation have undergone successful pregnancies
Lung Transplantation
Overview
Indications: end-stage parenchymal
disease or pulomonary hypertension.
Candidates are functionally incapacitate by
dyspnea and have a poor prognosis.
 Criteria varies according to the primary
disease process
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Single vs. Double Lung Transplant
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Single-lung transplantation may be
performed for selected patients with
chronic obstructive pulmonary disease,
whereas double-lung transplantation is
typically performed for patients with cystic
fibrosis, bullous emphysema, or vascular
diseases. Younger patients are more likely
to receive bilateral lung transplants.
Single Lung Transplantation
Often attempted without CPB. Procedure
is performed through a posterior
thoracotomy. A double-lumen tube must
be used for one-lung ventilation.
 CPB during transplantation of one lung is
based on arterial hypoxemia (spO2 <88%)
or a sudden increase in PA pressures.
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CPB for one lung
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When CPB is necessary, femoral-vein-tofemoral-artery bypass is employed during
left thoracotomy, whereas right-atrium-toaorta bypass is used during right
thoracotomy.
Double-Lung Transplantation
A "clamshell" transverse sternotomy can
be used for double-lung transplantation.
 The procedure is occasionally performed
with normothermic CPB; sequential
thoracotomies for double-lung
transplantation without CPB is more
common.
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Induction
modified rapid-sequence induction with
moderate head-up position
 A slow induction withketamine, etomidate, an
opioid is employed to avoid precipitous drops in
blood pressure.
 Succinylcholine or a nondepolarizing NMBA is
used to facilitate laryngoscopy.
 Hypoxemia and hypercarbia must be avoided to
prevent further increases in pulmonary artery
pressure.
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Maintenance of Anesthesia
Anesthesia is usually maintained with an opioid
infusion with or without a low dose of a volatile
agent.
 Intraoperative difficulties in ventilation are not
uncommon. Progressive retention of CO2 can
also be a problem intraoperatively. Ventilation
should be adjusted to maintain a normal arterial
pH to limit metabolic alkalosis.
 Patients with cystic fibrosis have copious
secretions and require frequent suctioning.
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Posttransplantation
Management
After anastomosis ventilation to both lungs
is resumed
 peak inspiratory pressures should be
maintained at the minimum pressure
compatible with good lung expansion, and
the inspired oxygen concentration should
be maintained at <60%.
 Methylprednisolone is usually given prior
to release of vascular clamps.
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Renal Transplantation
Renal Transplant Physiology
Renal Transplant Overview
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The success of renal transplantation, which is largely
due to advances in immunosuppressive therapy, has
greatly improved the quality of life for patients with endstage renal disease
With modern immunosuppressive regimens, cadaveric
transplants have achieved almost the same 3-year graft
survival rates (80–90%) as living related donor grafts
In addition, restrictions on candidates for renal
transplantation have gradually decreased; infection and
cancer are the only remaining absolute contraindications
with advanced age (>60) and severe cardiovascular
disease being relative contraindications
Preoperative Considerations
Preoperative optimization of the patient's
medical condition with dialysis is mandatory
 Current organ preservation techniques allow
ample time (24–48 h) for preoperative dialysis of
cadaveric recipients
 Living-related transplants are performed
electively with the donor and recipient
anesthetized simultaneously but in separate
rooms
 The recipient's serum potassium concentration
should be below 5.5 mEq/L, and existing
coagulopathies should be corrected
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Pharmacologic agents
All general anesthetic agents have been
employed without any apparent
detrimental effect on graft function;
nonetheless, sevoflurane is best avoided
 Atracurium, cisatracurium, and rocuronium
may be the muscle relaxants of choice, as
they are not primarily dependent on renal
excretion for elimination.
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Maintenance
Central venous pressure monitoring is very
useful in ensuring adequate hydration but
avoiding fluid overload
 Normal saline or half-normal saline
solutions are commonly used
 A urinary catheter is placed to assess graft
function postoperatively
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Case Study
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A 23-year-old woman develops fulminant
hepatic failure after ingesting wild
mushrooms. She is not expected to
survive without a liver transplant.
Preop, Induction, Maintenance
Ensure pt is T&C for prbc, ffp, plasma
 2 large bore IVs
 Art line placement for BP variability and
multiple lab draw
 RSI with anectine and etomidate. Cricoid
pressure until Ett placement confirmed
 Maintenance with Iso at 1 MAC without
use of N20
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Intra and Postop
Placement of central line with CVP and
Foley to monitor renal perfusion
 Have pressors ready for induction and
clamping of the blood vessels.
 Admit pt to ICU, may need to stay
intubated
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Question 1
Which organization oversees Organ Donation in
the U. S.?
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A. Health Department
B. National Institute of Health
C. United Network for Organ Sharing (UNOS)
D. Center for Disease Control
E. Department of Homeland Security
Question 2
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What is the most transplanted organ?
A. Liver
 B. Heart
 C. Kidney
 D. Pancreas
 E. Lung
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Question 3
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Which anesthetic agent is not
recommended for kidney transplant?
A. Low flow O2
 B. Desflurane
 C. Nitrous Oxide
 D. Sevoflurane
 E. Isoflurane
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Question 4
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Which of the following individuals do not make the best
candidates to receive a lung transplant?
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A. Cancer patients
B. HIV infection
C. Hepatitis B or Hepatits C with proven cirrhosis by liver
biopsy
D. Current substance abuse: tobacco, alcohol and illicit
drugs
E. Body weight less than 80% or greater than 120% of
predicted
F. All of the above
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Question 5
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Which of the following organs cannot be
transplanted at this time?
A. Liver
 B. Kidney
 C. Heart
 D. Lung
 E. Brain
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